Stages of syphilis

Reviewed by our clinical team

Syphilis is a sexually transmitted infection (STI). Symptoms of syphilis can be hard to spot and often change over time, even going away completely, meaning you may not know you are infected. However, if left untreated, syphilis can lead to serious and even life-threatening problems.

This article explains in more depth what syphilis is, defining each of the four stages of syphilis and outlining the corresponding signs and symptoms. It also provides information on how syphilis is spread, how to test for this STI and how syphilis is treated.

What is syphilis?

Syphilis is a sexually transmitted infection (STI) caused by a bacteria called Treponema pallidum. It can spread easily and can have long-term health implications.

How do you catch syphilis?

Syphilis is caught from an infected person through bodily contact. It is usually transmitted during unprotected sex including vaginal, oral, or anal sex. However, it can also be passed on from contact with a syphilitic ulcer that is present on an infected person’s penis, vagina, bottom, or inside their mouth.

It is also possible for syphilis to be passed from a mother to an unborn baby during pregnancy (congenital syphilis), through the sharing of needles used by an infected person and from a blood or organ transplant (although this is incredibly rare).

How long does it take syphilis to show up?

It usually takes at least 3 weeks for symptoms of syphilis to show up after you’ve been infected but it can take up to 3 months for stage one of syphilis to develop visible symptoms. This is why it is recommended to have an STI test at least every six months if having casual sex, and/or before having sex at the start of a new relationship. In addition to routine sexual health screenings, condoms also protect against STIs.

Is syphilis common?

Syphilis is less common in the UK than other STIs, such as Chlamydia and Herpes, but it is becoming more prevalent. For example, new diagnoses of syphilis in England increased between 2013 and 2018 from 3344 to 7541. However, this number of cases is still low when compared to Chlamydia and Gonorrhoea which had 229,213 and 70,922 reported cases in 2019, respectively.

What are the 4 stages of syphilis? 

Syphilis develops in four stages. Each stage has different signs and symptoms. The four stages of syphilis are categorised as:

• Primary
• Secondary
• Latent
• Tertiary

Primary stage symptoms of syphilis

Stage one of syphilis usually occurs ten days to 3 months after infection. Unlike other STI symptoms in men and STI symptoms in women, initial signs of syphilis are so mild that you may not even notice them. The main indication of the primary stage of syphilis is a chancre.

Chancre

A chancre, also known as a syphilitic sore, is a small, painless lesion. It typically starts out looking red or crusty but over a few days to weeks, it becomes raised and hard and releases a serous fluid. Normally only one chancre will appear but some people may get several.

Where do syphilis chancres appear?

Chancres can occur in, on, or around the:

• Penis
• Vagina
• Rectum
• Anus
• Lips
• Mouth

A chancre will last for 3 to 6 weeks and then heal regardless of whether a person receives treatment. However, this does not mean the infection has gone and syphilis will progress to the second stage if not treated.

Secondary stage symptoms of syphilis

Between 2 and 8 weeks after the chancre disappears, the second stage of syphilis will begin. Like the primary stage, the secondary stage of syphilis is highly contagious. The symptoms at this stage include:

• Red, blotchy skin rashes which often occur on the palms of the hands or soles of the feet
• Condyloma lata (lesions)
• Fever
• Small skin growths (similar to genital warts) that appear on the vulva and/or anus
• Swollen lymph nodes
• Sore throat
• Hair loss
• Headaches
• Weight loss
• Fatigue
• White patches in the mouth

What happens if you do not treat early stages of syphilis?

If STI treatment is not sought for syphilis whilst it is in its early stages, it stays in the body but becomes hidden, showing no signs or symptoms of infection. This can lead to life-threatening conditions years after you were initially infected including heart problems, seizures, personality changes, and nerve issues.

Latent stages of syphilis

Following the conclusion of the secondary stage of syphilis, the infection lies dormant, displaying no signs or symptoms. Latent syphilis is separated into stages:

• Early latent syphilis: The first 12 months after the primary and secondary stages have passed.
• Late latent syphilis: Where a person has been infected for longer than 12 months. During the first 4 years of latent syphilis, patients are still considered infectious and can relapse into the secondary stage.
• Latent syphilis of unknown duration: This stage is ordinarily not infectious, except for pregnant women, who can transmit the infection to their unborn child(ren).

What is tertiary syphilis?

Tertiary syphilis, also known as third or late-stage syphilis, is a stage that can occur years after the initial infection. It can cause serious, life-threatening damage to the body. Whilst syphilis can still be treated at this stage, it may not be possible to recover from the damage that the infection has done.

Where does tertiary syphilis affect?

Tertiary syphilis can affect many areas of the body including the brain, heart, eyes, and nervous system.

Neurosyphilis

Neurosyphilis is when syphilis leads to an infection of the brain and/or spinal cord. It can cause:

• Personality changes
• Forgetfulness
• Confusion
• Delusions
• Seizures
• Psychosis
• Bladder dysfunction
• Ataxia

Ocular syphilis

Ocular syphilis is another complication of untreated syphilis. It affects the eye and eye structures. It can result in:

• Inflammation of the middle eye
• Swelling that damages the optic nerve
• A painless decrease in vision
• Blood vessels growing into the cornea

Otosyphilis

Otosyphilis is a less recognised complication of untreated syphilis that can lead to irreversible hearing loss. It can also cause:

• Vertigo
• Tinnitus
• Balance issues

Are syphilis and HIV related?

HIV and syphilis affect similar patient groups and it is common for co-infection to occur. The presence of chancres or lesions on the skin of a person with syphilis can make it easier for HIV to be transmitted into the bloodstream.

What’s more, syphilis may present itself with non-typical symptoms in the HIV-positive patient. In HIV-positive patients, there is a higher rate of symptomless primary syphilis and proportionately more HIV-positive patients present with secondary disease. Secondary syphilis infections may also be more aggressive.

This is why it is recommended that patients with HIV symptoms are tested for syphilis and those with syphilis symptoms undergo an HIV test too.

How to test for syphilis

STI tests are the only way to confirm a syphilis infection. In the UK, you can visit your GP for advice on STI testing tests or go to a sexual health clinic. Some pharmacies also offer at-home testing kits and/or a genital photo assessment service, carried out by a doctor.

STI tests for women

STI tests for women will vary depending on whether you are doing a full sexual health screening or are testing for a specific infection such as syphilis. An STI test may involve a visual examination of your genitals and/or a urine sample, blood sample, urethral swab and vaginal swab. Our at-home female STI test tests for chlamydia, gonorrhoea, syphilis and HIV using vaginal swabs and a finger prick blood sample that you take yourself and then send off in the post.

STI tests for men

As for women, STI tests for men will depend on the type of screening being done. For syphilis, an examination of the penis and anus is likely to be conducted. In addition, a swab from visible sores may be taken alongside a blood sample.

Home test kits can also be used. Our male STI kit tests for four different STIs, including syphilis using a urine sample and finger prick blood sample. There is also a man-to-man STI kit which is specifically designed for men who have sex with men.

Treatment for syphilis

Early-stage syphilis is treated with antibiotics. This is normally penicillin and can be administered even during pregnancy. Usually, treatment is done via injection and an infected person may require one or more doses. In some situations, tablet antibiotics may be offered.

In the tertiary stage of syphilis, antibiotics can still treat the STI and prevent further damage but may not reverse any harm that has already been caused by the infection.
Having treatment for syphilis doesn’t protect you from further infections. If you are reinfected, you will need treatment again.

What to do if you test positive for syphilis?

If you test positive for syphilis, you should seek STI treatment with your GP or local sexual health clinic. Bear in mind that even if you test negative for an STI, you could still be infected: you may have just tested too early after exposure to the infection.

In summary, syphilis is an STI caused by bacteria. It is spread through bodily contact including unprotected sex and contact with chancres. Syphilis has four stages, and symptoms in the primary stage are often hard to detect. If left untreated, syphilis can lead to life-threatening complications. It is easily tested for and can be treated with antibiotics.

For more information about your sexual health, take a look at our guide to the difference between STIs and STDs. We also have some useful advice on STI symptoms in women and STI symptoms in men.

References

https://www.nhs.uk/conditions/syphilis/
https://www.gov.uk/government/collections/syphilis-surveillance-data-and-management
https://www.nhsinform.scot/illnesses-and-conditions/sexual-and-reproductive/syphilis
https://www.tht.org.uk/hiv-and-sexual-health/sexual-health/improving-your-sexual-health/healthy-sex-life
https://www.thesexualhealthhub.co.uk/stis/types-of-stis/
https://cks.nice.org.uk/topics/syphilis/background-information/prevalence/
https://www.gov.uk/government/news/sti-rates-remain-a-concern-despite-fall-in-2020  
https://www.shl.uk/about-stis/syphilis
https://www.sciencedirect.com/topics/medicine-and-dentistry/chancre
https://www.tht.org.uk/hiv-and-sexual-health/sexual-health/stis/syphilis
https://111.wales.nhs.uk/Syphilis/
https://www.sciencedirect.com/topics/medicine-and-dentistry/latent-syphilis
https://www.ncbi.nlm.nih.gov/books/NBK540979/
https://www.ncbi.nlm.nih.gov/books/NBK558957/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8530448/
https://pubmed.ncbi.nlm.nih.gov/15219556/